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Firm Name: Contact Name:
Email Address: Phone:
City: State: Zip:

No. of Employees:    

Attorney Name Years of Practice
with Firm
Average # of Hours
per Week

1. Has the firm been continuously insured for malpractice for the last five years?
If No, for how many years has the firm been continuously insured?

2. If the firm has current coverage, please provide the following information:
Current Carrier: Expiration Date:  
Limits of Liability: / Deductible: Annual Premium:

3. Has the firm, or any attorneys within the firm, had any professional liability claims or disciplinary
complaints made against them in the past five years?

4. Please list the area of law that your firm engages in and put the percentages of billable hours devoted to each area of the law.
Percentages must total 100%

Admiralty/Marine - Defense Environmental Personal Injury/Property Damage - Defense
Admiralty/Marine - Plaintiff Family Law Personal Injury/Property Damage - Plaintiff
Banking/Financial Institutions Immigration/Naturalization Real Estate/Title - Commercial
Business Transaction/Commercial Law Intellectual Property Real Estate/Title - Residential
Civil/Commercial Litigation - Defense International Law Securities (S.E.C.)
Civil/Commercial Litigation - Plaintiff Labor Management Representation Taxation
Civil Rights/Discrimination Labor Union Representation Wills, Estate, Trust and Probate
Collection and Bankruptcy Local Government Workers Compensation - Defense
Corporate Business Organization Mass Tort/Class Action Workers Compensation - Plaintiff

5. I would also like a quote for:

Hacking, Identity Theft, Private Information Loss, Security Breaches and More
Discrimination, Sexual Harrasment, Wrongful Termination, Retaliation and More
Employees’ Medical and Disability Expenses Related to on the Job Injuries
Employee Theft, Employee Theft of Client Property, Forgery or Alteration, Robbery and Safe Burglary, Computer and Funds Transfer Fraud and More
Property Damage or Bodily Injury Claims

How did you hear about us? (optional):




This Form Is For Estimate Purposes Only.
Coverage May be Bound Only Upon Submission and Acceptance of a Completed Application.
Gilsbar Specialty Insurance Services, LLC
P. O. Box 998, Covington, Louisiana 70434